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Open posterior adrenalectomy
Open Posterior Adrenalectomy Christoph Nies, MD, and Matthias Rothmund, MD, FACS
he adrenal glands are located centrally in the body— close to the midline in the frontal plane and just posterior to the middle of the sagittal plane. It is, therefore, understandable that several different surgical approaches have been described. Besides the classical ventral transabdominal approach, the adrenal glands can be reached via a thoracoabdominal incision (indicated for the removal of large adrenal tumors, eg, adrenocortical carcinomas) or via a lateral flank incision, which is the preferred route for many urologists. In 1936, Young, a urologist from Baltimore, first described the posterior approach with the patient in the prone position, allowing bilateral adrenal exploration without the need to reposition the patient.1 In the last decade, the spectrum of surgical access to the adrenal glands has been broadened by the introduction of the various techniques in minimally invasive adrenalectomy.
should therefore not be approached via the open posterior route. Furthermore, the adrenal vein can be identified only at a late phase of the dissection. Pheochromocytomas have therefore been considered as a contraindication for open posterior adrenalectomy, since early ligation of the adrenal vein has been mandatory in operations for catecholamine-secreting tumors to avoid excessive hormone liberation during dissection. However, since the use of alpha-receptorblocking agents is routine, adrenalectomy for pheochromocytoma has become safe, and early ligation of the adrenal vein is more of a theoretical consideration. Today, adrenalectomy can be performed safely via the open posterior approach.5 The ideal indications for open posterior adrenalectomy are benign adrenal lesions, smaller than 5 to 6 cm, regardless of whether they are hormonally active or not.
INDICATIONS
PREPARATION OF THE PATIENT
Several aspects have to be considered when the appropriate approach to the adrenal glands is chosen: ● Size of the tumor, ● Hormonal activity of the tumor, ● The presumed histological diagnosis (benign versus malignant), and ● Location of the lesion (unilateral versus bilateral). In the era before minimally invasive adrenalectomy was available, posterior open adrenalectomy was the access of choice, since it was considered to be the safest approach associated with the lowest morbidity. 2– 4 However, it is only suitable for the removal of small adrenal tumors, because the operative field is both small and deep. This results in difficult visualization and does not allow a controlled dissection of larger lesions. Tumors with a diameter of more than 5 to 6 cm
Preparation of the patient for the operation is not different from adrenalectomies using other surgical approaches. In patients with aldosterone-producing adenomas, the electrolyte disturbances (hypokalemia, acidosis) have to be corrected and the blood pressure must be medically controlled. Similarly, electrolyte levels and blood pressure need to be normalized in patients with Cushing syndrome. In cases with severe hypercortisolism, preoperative treatment with ketoconazole may be indicated. Most importantly, patients with Cushing syndrome are at risk for thromboembolic and wound complications. Therefore, perioperative low-dose heparin and antibiotic prophylaxis should be considered. If the operation is performed to remove a pheochromocytoma, adequate preoperative treatment with alpha-receptor-blocking agents (e.g., phenoxybenzamine) is mandatory and given with increasing dosages over a period of 7 to 10 days until patients experience side effects (orthostatic hypotension, “stuffy” nose). Usually a dose of 1.5 to 2 mg/kg body weight is required. During this period, the patient should be encouraged to drink liquids as much as possible to correct any volume depletion. If tachycardia is signifi-
T
From theDepartment of Visceral, Thoracic, and Vascular Surgery, PhilippsUniversity, Marburg, Germany. Address reprint requests to Christoph Nies, MD, Klinik fu¨r Visceral-, Thoraxund Gefa¨chirurgie, Klinikum der Philipps-Universita¨t, Baldingerstr., D-35033 Murburg; Germany. Copyright 2002, Elsevier Science (USA). All rights reserved. 1524-153X/02/0404-0110$35.00/0 doi:10.1053/otgn.2002.35347
296
Operative Techniques in General Surgery, Vol 4, No 4 (December), 2002: pp 296 –303
297
Open Posterior Adrenalectomy
cant, a beta-receptor-blocking agent may additionally be given, however, only after the institution of alpha-blockade.
VALUE OF THE OPEN POSTERIOR APPROACH A potential complication of the open posterior approach is irritation of the subcostal nerve. In a study comparing the conventional anterior and posterior approaches in patients undergoing bilateral adrenalectomy for Cushing disease, Buell and coworkers6 found that most patients undergoing the posterior approach developed long-term incisional pain, which can be severe and incapacitating. They, therefore, recommended that the posterior approach be reserved for patients in whom the anterior approach may pose some technical difficulties. Most authors, however, consider posterior adrenalectomy as the least invasive conventional approach to the adrenal glands. Compared with other conventional techniques, the posterior approach is associated with a significantly shorter operative time7,8 and with a shorter hospital stay.3,7,8 This is mainly due to the fact that the peritoneal cavity is not opened and bowel function is usually normal immediately after the operation. Patients can therefore tolerate a regular diet earlier than patients undergoing open transabdominal adrenalectomy.6 In addition, the requirement for pain medication in the immediate postoperative period after an operation via the posterior approach is significantly lower.6 Another important aspect is the fact
that an operation on both adrenals can be performed without turning the patient to expose the opposite gland. Among the conventional approaches to the adrenal glands, only the ventral transabdominal access shares this advantage, but as outlined above, it is more incapacitating for the patient. Therefore, for most endocrine surgeons, the open posterior approach was the access of choice to the adrenal glands. This picture changed considerably with the introduction of minimally invasive adrenalectomy. Although there are no randomized controlled trials available in which conventional and minimally invasive approaches to the adrenals are compared, all comparative studies using historical control groups have shown advantages for the minimally invasive techniques. Patients have less postoperative pain, a shorter hospital stay, a shorter period of convalescence, and a better cosmetic result.8 –13 In most endocrine surgical centers, laparoscopic or retroperitoneoscopic adrenalectomy has become the procedure of choice in the treatment of most benign adrenal tumors up to a size of 5 to 7 cm. This is exactly the same spectrum of adrenal lesions suitable for the open posterior approach, which has, therefore, lost most of its former importance. Currently, it is rarely done. To perform an appropriate technology assessment, minimally invasive adrenalectomy should be compared with open posterior adrenalectomy in a controlled randomized trial.
SURGICAL TECHNIQUE
1
The patient is placed in the prone position on the operating table. Pillows or rolled blankets are placed underneath the chest and pelvis to reduce pressure on the abdomen, allowing the peritoneal organs to fall away from the retroperitoneum. The table is “broken” at the level just above the iliac crest to eliminate lumbar lordosis and to allow flexion of the hips. The lower legs are elevated with soft pillows and the knees are flexed.
298
Nies and Rothmund
2
A curvilinear incision is made beginning over the costovertebral joint of the tenth rib and runs caudally until it reaches the twelfth rib, which it follows laterally. The subcutaneous tissues, latissimus dorsi muscle, and posterior layer of the thoracolumbar fascia are incised. The sacrospinal muscle and the lateral portions of the lower ribs are thereby exposed.
Open Posterior Adrenalectomy
3
The sacrospinalis muscle does not need to be injured. Its “belly” can be retracted medially toward the vertebral column. The ribs are thereby further exposed. Small vessels entering the sacrospinalis muscle laterally should be ligated.
299
300
Nies and Rothmund
4
The tissue over the twelfth rib, including the periosteum, is incised over the entire length of the rib. The rib is then isolated within the periosteum. Great care has to be taken to avoid injury to the underlying pleura and the subcostal neurovascular bundle.
5
After circumferential isolation of the twelfth rib, it is transected using a rib cutter as close to the costovertebral joint as possible. Again, it is important not to injure the pleura and to protect the neurovascular bundle during this maneuver.
301
Open Posterior Adrenalectomy
6
The ventral portion of the bed of the twelfth rib (periosteum, middle and ventral lamella of the thoracolumbar fascia) is incised. The subcostal neurovascular bundle now comes into sight. The nerve can be separated from the vessels. It is advisable to ligate and divide the vessels at this point, otherwise it is very likely that they will subsequently tear. The nerve is preserved and retracted upwards. The pleural reflexion is also visible at this point and should be gently pushed upwards. The retroperitoneal space has now been reached and the surgeon has a view of the posterior aspect of Gerota’s fascia.
7
Gerota’s fascia is incised and the perirenal fat divided. The posterior surface of the kidney is exposed. The upper pole of the kidney is bluntly dissected free and retracted caudally with an angulated retraction device. The lateral aspect of the adrenal comes into view and is identified by its bright yellow color. On the left side it is found medial to the upper pole of the kidney, and on the right side it is cephalad and medial to the kidney. The adrenal gland is carefully dissected free. It is advisable to leave the attachments to the upper pole of the kidney as long as possible, since this facilitates exposure of the gland, which is retracted downwards with the kidney. Small vessels can be coagulated or clipped. It may be difficult to ligate vessels, because the operative field is rather deep during this phase of the operation. The adrenal vein becomes visible after the gland has been completely mobilized. On the right side, it is a short and wide vessel, which empties into the inferior vena cava from the medial margin of the gland. On the left side, the vein is smaller and longer and drains into the renal vein. Close to the renal vein, it joins with the inferior phrenic vein, which may cause bleeding if the adrenal vein is transected close to the renal vein.
302
Nies and Rothmund
8
Clips are placed across the adrenal vein before it is cut. Great care must be taken to avoid bleeding at this point, since it may be difficult to control. Again, clips should be used instead of ligatures, which are difficult to tie. After the adrenal vein is divided, the last attachments of the adrenal gland to the upper pole of the kidney are divided and the specimen can be removed.
9
When the wound is closed, it is most important not to include the subcostal nerve in a suture. Chronic postoperative pain would be the result, which is one cause of operative morbidity associated with this procedure. If the pleura has been injured, the anesthesiologist is asked to maximally inflate the lung while the pleural defect is closed. If a lung injury can be ruled out with certainty, a chest tube may not be necessary. The anterior and middle layers of the thoracolumbar fascia are closed together with a single running suture line. If tension on the suture line is excessive, the inferior edge of the conjoined fascia can be sewn to the sacrospinalis muscle. The posterior layer of the fascia, the latissimus dorsi muscle, and the skin are then closed separately.
303
Open Posterior Adrenalectomy
REFERENCES 1. Young HH: A technique for simultaneous exposure and operation on the adrenals. Surg Gynecol Obstet 63:179 –188, 1936 2. Proye CA, Huart JY, Curvillier XD, et al: Safety of the posterior approach in adrenal surgery: experience in 105 cases. Surgery 114:1126 –1131, 1993 3. Russell CF, Hamberger B, van Heerden JA, et al: Adrenalectomy: anterior or posterior approach? Am J Surg 144:322–324, 1982 4. Watson RG, van Heerden JA, Northcutt RC, et al: Results of adrenal surgery for Cushing’s syndrome: 10 years’ experience. World J Surg 10:531–538, 1986 5. Grant CS: Pheochromocytoma, in Clark OH, Duh QY (eds): Textbook of Endocrine Surgery. Philadelphia, PA, Saunders, 1997, pp 513–533 6. Buell JF, Alexander HR, Norton JA, et al: Bilateral adrenalectomy for Cushing’s syndrome—anterior versus posterior approach. Ann Surg 225:63– 68, 1997 7. Linos DA, Stylopoulos N, Boukis M: Anterior, posterior, and lapa-
8. 9.
10.
11.
12.
13.
roscopic approach for the management of adrenal diseases? Am J Surg 173:120 –125, 1997 Prinz RA: A comparison of laparoscopic and open adrenalectomy. Arch Surg 130:489 – 494, 1995 Brunt LM, Doherty GM, Norton JA, et al: Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasms. J Am Coll Surg 183:1–10, 1996 Guazzoni G, Montorsi F, Bocciardi A, et al: Transperitoneal laparoscopic versus open adrenalectomy for benign hyperfunctioning adrenal tumors: A comparative study. J Urol 153:1597– 1600, 1995 MacGillivray DC, Schichman SJ, Ferrer FA, et al: A comparison of open vs laparoscopic adrenalectomy. Surg Endosc 10:987– 990, 1996 Mobius E, Nies C, Rothmund M: Surgical treatment of pheochromocytomas: Laparoscopic or conventional? Surg Endosc 13:35– 39, 1999 Naito S, Uozumi J, Ichimiya H, et al: Laparoscopic adrenalectomy: Comparison with open adrenalectomy. Eur Urol 26:253– 257, 1994
he adrenal glands are located centrally in the body— close to the midline in the frontal plane and just posterior to the middle of the sagittal plane. It is, therefore, understandable that several different surgical approaches have been described. Besides the classical ventral transabdominal approach, the adrenal glands can be reached via a thoracoabdominal incision (indicated for the removal of large adrenal tumors, eg, adrenocortical carcinomas) or via a lateral flank incision, which is the preferred route for many urologists. In 1936, Young, a urologist from Baltimore, first described the posterior approach with the patient in the prone position, allowing bilateral adrenal exploration without the need to reposition the patient.1 In the last decade, the spectrum of surgical access to the adrenal glands has been broadened by the introduction of the various techniques in minimally invasive adrenalectomy.
should therefore not be approached via the open posterior route. Furthermore, the adrenal vein can be identified only at a late phase of the dissection. Pheochromocytomas have therefore been considered as a contraindication for open posterior adrenalectomy, since early ligation of the adrenal vein has been mandatory in operations for catecholamine-secreting tumors to avoid excessive hormone liberation during dissection. However, since the use of alpha-receptorblocking agents is routine, adrenalectomy for pheochromocytoma has become safe, and early ligation of the adrenal vein is more of a theoretical consideration. Today, adrenalectomy can be performed safely via the open posterior approach.5 The ideal indications for open posterior adrenalectomy are benign adrenal lesions, smaller than 5 to 6 cm, regardless of whether they are hormonally active or not.
INDICATIONS
PREPARATION OF THE PATIENT
Several aspects have to be considered when the appropriate approach to the adrenal glands is chosen: ● Size of the tumor, ● Hormonal activity of the tumor, ● The presumed histological diagnosis (benign versus malignant), and ● Location of the lesion (unilateral versus bilateral). In the era before minimally invasive adrenalectomy was available, posterior open adrenalectomy was the access of choice, since it was considered to be the safest approach associated with the lowest morbidity. 2– 4 However, it is only suitable for the removal of small adrenal tumors, because the operative field is both small and deep. This results in difficult visualization and does not allow a controlled dissection of larger lesions. Tumors with a diameter of more than 5 to 6 cm
Preparation of the patient for the operation is not different from adrenalectomies using other surgical approaches. In patients with aldosterone-producing adenomas, the electrolyte disturbances (hypokalemia, acidosis) have to be corrected and the blood pressure must be medically controlled. Similarly, electrolyte levels and blood pressure need to be normalized in patients with Cushing syndrome. In cases with severe hypercortisolism, preoperative treatment with ketoconazole may be indicated. Most importantly, patients with Cushing syndrome are at risk for thromboembolic and wound complications. Therefore, perioperative low-dose heparin and antibiotic prophylaxis should be considered. If the operation is performed to remove a pheochromocytoma, adequate preoperative treatment with alpha-receptor-blocking agents (e.g., phenoxybenzamine) is mandatory and given with increasing dosages over a period of 7 to 10 days until patients experience side effects (orthostatic hypotension, “stuffy” nose). Usually a dose of 1.5 to 2 mg/kg body weight is required. During this period, the patient should be encouraged to drink liquids as much as possible to correct any volume depletion. If tachycardia is signifi-
T
From theDepartment of Visceral, Thoracic, and Vascular Surgery, PhilippsUniversity, Marburg, Germany. Address reprint requests to Christoph Nies, MD, Klinik fu¨r Visceral-, Thoraxund Gefa¨chirurgie, Klinikum der Philipps-Universita¨t, Baldingerstr., D-35033 Murburg; Germany. Copyright 2002, Elsevier Science (USA). All rights reserved. 1524-153X/02/0404-0110$35.00/0 doi:10.1053/otgn.2002.35347
296
Operative Techniques in General Surgery, Vol 4, No 4 (December), 2002: pp 296 –303
297
Open Posterior Adrenalectomy
cant, a beta-receptor-blocking agent may additionally be given, however, only after the institution of alpha-blockade.
VALUE OF THE OPEN POSTERIOR APPROACH A potential complication of the open posterior approach is irritation of the subcostal nerve. In a study comparing the conventional anterior and posterior approaches in patients undergoing bilateral adrenalectomy for Cushing disease, Buell and coworkers6 found that most patients undergoing the posterior approach developed long-term incisional pain, which can be severe and incapacitating. They, therefore, recommended that the posterior approach be reserved for patients in whom the anterior approach may pose some technical difficulties. Most authors, however, consider posterior adrenalectomy as the least invasive conventional approach to the adrenal glands. Compared with other conventional techniques, the posterior approach is associated with a significantly shorter operative time7,8 and with a shorter hospital stay.3,7,8 This is mainly due to the fact that the peritoneal cavity is not opened and bowel function is usually normal immediately after the operation. Patients can therefore tolerate a regular diet earlier than patients undergoing open transabdominal adrenalectomy.6 In addition, the requirement for pain medication in the immediate postoperative period after an operation via the posterior approach is significantly lower.6 Another important aspect is the fact
that an operation on both adrenals can be performed without turning the patient to expose the opposite gland. Among the conventional approaches to the adrenal glands, only the ventral transabdominal access shares this advantage, but as outlined above, it is more incapacitating for the patient. Therefore, for most endocrine surgeons, the open posterior approach was the access of choice to the adrenal glands. This picture changed considerably with the introduction of minimally invasive adrenalectomy. Although there are no randomized controlled trials available in which conventional and minimally invasive approaches to the adrenals are compared, all comparative studies using historical control groups have shown advantages for the minimally invasive techniques. Patients have less postoperative pain, a shorter hospital stay, a shorter period of convalescence, and a better cosmetic result.8 –13 In most endocrine surgical centers, laparoscopic or retroperitoneoscopic adrenalectomy has become the procedure of choice in the treatment of most benign adrenal tumors up to a size of 5 to 7 cm. This is exactly the same spectrum of adrenal lesions suitable for the open posterior approach, which has, therefore, lost most of its former importance. Currently, it is rarely done. To perform an appropriate technology assessment, minimally invasive adrenalectomy should be compared with open posterior adrenalectomy in a controlled randomized trial.
SURGICAL TECHNIQUE
1
The patient is placed in the prone position on the operating table. Pillows or rolled blankets are placed underneath the chest and pelvis to reduce pressure on the abdomen, allowing the peritoneal organs to fall away from the retroperitoneum. The table is “broken” at the level just above the iliac crest to eliminate lumbar lordosis and to allow flexion of the hips. The lower legs are elevated with soft pillows and the knees are flexed.
298
Nies and Rothmund
2
A curvilinear incision is made beginning over the costovertebral joint of the tenth rib and runs caudally until it reaches the twelfth rib, which it follows laterally. The subcutaneous tissues, latissimus dorsi muscle, and posterior layer of the thoracolumbar fascia are incised. The sacrospinal muscle and the lateral portions of the lower ribs are thereby exposed.
Open Posterior Adrenalectomy
3
The sacrospinalis muscle does not need to be injured. Its “belly” can be retracted medially toward the vertebral column. The ribs are thereby further exposed. Small vessels entering the sacrospinalis muscle laterally should be ligated.
299
300
Nies and Rothmund
4
The tissue over the twelfth rib, including the periosteum, is incised over the entire length of the rib. The rib is then isolated within the periosteum. Great care has to be taken to avoid injury to the underlying pleura and the subcostal neurovascular bundle.
5
After circumferential isolation of the twelfth rib, it is transected using a rib cutter as close to the costovertebral joint as possible. Again, it is important not to injure the pleura and to protect the neurovascular bundle during this maneuver.
301
Open Posterior Adrenalectomy
6
The ventral portion of the bed of the twelfth rib (periosteum, middle and ventral lamella of the thoracolumbar fascia) is incised. The subcostal neurovascular bundle now comes into sight. The nerve can be separated from the vessels. It is advisable to ligate and divide the vessels at this point, otherwise it is very likely that they will subsequently tear. The nerve is preserved and retracted upwards. The pleural reflexion is also visible at this point and should be gently pushed upwards. The retroperitoneal space has now been reached and the surgeon has a view of the posterior aspect of Gerota’s fascia.
7
Gerota’s fascia is incised and the perirenal fat divided. The posterior surface of the kidney is exposed. The upper pole of the kidney is bluntly dissected free and retracted caudally with an angulated retraction device. The lateral aspect of the adrenal comes into view and is identified by its bright yellow color. On the left side it is found medial to the upper pole of the kidney, and on the right side it is cephalad and medial to the kidney. The adrenal gland is carefully dissected free. It is advisable to leave the attachments to the upper pole of the kidney as long as possible, since this facilitates exposure of the gland, which is retracted downwards with the kidney. Small vessels can be coagulated or clipped. It may be difficult to ligate vessels, because the operative field is rather deep during this phase of the operation. The adrenal vein becomes visible after the gland has been completely mobilized. On the right side, it is a short and wide vessel, which empties into the inferior vena cava from the medial margin of the gland. On the left side, the vein is smaller and longer and drains into the renal vein. Close to the renal vein, it joins with the inferior phrenic vein, which may cause bleeding if the adrenal vein is transected close to the renal vein.
302
Nies and Rothmund
8
Clips are placed across the adrenal vein before it is cut. Great care must be taken to avoid bleeding at this point, since it may be difficult to control. Again, clips should be used instead of ligatures, which are difficult to tie. After the adrenal vein is divided, the last attachments of the adrenal gland to the upper pole of the kidney are divided and the specimen can be removed.
9
When the wound is closed, it is most important not to include the subcostal nerve in a suture. Chronic postoperative pain would be the result, which is one cause of operative morbidity associated with this procedure. If the pleura has been injured, the anesthesiologist is asked to maximally inflate the lung while the pleural defect is closed. If a lung injury can be ruled out with certainty, a chest tube may not be necessary. The anterior and middle layers of the thoracolumbar fascia are closed together with a single running suture line. If tension on the suture line is excessive, the inferior edge of the conjoined fascia can be sewn to the sacrospinalis muscle. The posterior layer of the fascia, the latissimus dorsi muscle, and the skin are then closed separately.
303
Open Posterior Adrenalectomy
REFERENCES 1. Young HH: A technique for simultaneous exposure and operation on the adrenals. Surg Gynecol Obstet 63:179 –188, 1936 2. Proye CA, Huart JY, Curvillier XD, et al: Safety of the posterior approach in adrenal surgery: experience in 105 cases. Surgery 114:1126 –1131, 1993 3. Russell CF, Hamberger B, van Heerden JA, et al: Adrenalectomy: anterior or posterior approach? Am J Surg 144:322–324, 1982 4. Watson RG, van Heerden JA, Northcutt RC, et al: Results of adrenal surgery for Cushing’s syndrome: 10 years’ experience. World J Surg 10:531–538, 1986 5. Grant CS: Pheochromocytoma, in Clark OH, Duh QY (eds): Textbook of Endocrine Surgery. Philadelphia, PA, Saunders, 1997, pp 513–533 6. Buell JF, Alexander HR, Norton JA, et al: Bilateral adrenalectomy for Cushing’s syndrome—anterior versus posterior approach. Ann Surg 225:63– 68, 1997 7. Linos DA, Stylopoulos N, Boukis M: Anterior, posterior, and lapa-
8. 9.
10.
11.
12.
13.
roscopic approach for the management of adrenal diseases? Am J Surg 173:120 –125, 1997 Prinz RA: A comparison of laparoscopic and open adrenalectomy. Arch Surg 130:489 – 494, 1995 Brunt LM, Doherty GM, Norton JA, et al: Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasms. J Am Coll Surg 183:1–10, 1996 Guazzoni G, Montorsi F, Bocciardi A, et al: Transperitoneal laparoscopic versus open adrenalectomy for benign hyperfunctioning adrenal tumors: A comparative study. J Urol 153:1597– 1600, 1995 MacGillivray DC, Schichman SJ, Ferrer FA, et al: A comparison of open vs laparoscopic adrenalectomy. Surg Endosc 10:987– 990, 1996 Mobius E, Nies C, Rothmund M: Surgical treatment of pheochromocytomas: Laparoscopic or conventional? Surg Endosc 13:35– 39, 1999 Naito S, Uozumi J, Ichimiya H, et al: Laparoscopic adrenalectomy: Comparison with open adrenalectomy. Eur Urol 26:253– 257, 1994